Incident investigation·September 25, 2025

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Case Management visit to follow-up on multiple incidents reported to Community Care Licensing. LPA met with Clinical Director Yolanda Torres and Director Jonathan Wheeler and discussed the purpose of the visit. Community Care Licensing received an incident report on 9/16/2025 in which it was reported that Resident #1s (R1) and Staff 1 (S1) had a verbal altercation. Interview with Clinical Director established that S1 denied the allegations. Statement from Staff 2 (S2) established that S2 observed S1 cursing at R1. LPA was unable to interview R1 as they are no longer present at the facility due to increased psychiatric behaviors. Additionally, on 9/16/2025, CCL received an LIC624, Unusual Incident Report regarding R2 being issued the incorrect medication. According to report, R2 was issued a lower dose of a medication than they are prescribed and the error was reported to all required entities. R2's Physician Report established they require medication management. Clinical Director stated there were no adverse reactions to medication. During today's visit, LPA conducted a health and safety check of the residents in care and provided consultation. On today's date, one deficiency was issued for medication administration. An exit interview was conducted with Clinical Director to whom a copy of their appeal rights, 809-D, LIC811, and this report were provided to.